CT in post-traumatic hypoperfusion complex��a pictorial review

Hypoperfusion complex is an uncommon entity found on computed tomography (CT) of blunt trauma. It is more common in children compared to adults. Everyone should be aware of this entity to interact with clinicians to aid in triage and management of patients in view of poor prognosis. It is also important to prevent unnecessary laparotomies by confusing abdominal organ injuries. There are certain visceral and vascular findings described on abdominal CT that would alert the radiologist for this entity. This pictorial review should increase radiologists' awareness and recognition of the CT manifestations of hypoperfusion complex before an irreversible state of shock occurs in blunt abdominal trauma.     

Pediatric liver tumors – a pictorial review

Hepatic masses constitute about 5–6% of all intra-abdominal masses in children. The majority of liver tumors in children are malignant; these malignant liver tumors constitute the third most common intra-abdominal malignancy in the pediatric age group after Wilms’ tumor and neuroblastoma. Only about one third of the liver tumors are benign. A differential diagnosis of liver tumors in children can be obtained based on the age of the child, clinical information (in particular AFP) and imaging characteristics. The purpose of this review is to report typical clinical and imaging characteristics of benign and malignant primary liver tumors in children.     

Digital breast tomosynthesis of gynecomastia and associated findings—a pictorial review

Men referred for breast imaging most frequently present with a unilateral palpated breast lump or breast enlargement. In the vast majority of these cases, the cause is benign and the most common etiology is gynecomastia. This pictorial review illustrates the appearance by full field digital mammography and digital breast tomosynthesis of gynecomastia as well as additional findings in the male breast including sternalis muscle and hypertrophied pectoralis muscle, lipoma, intramammary lymph node, fat necrosis, breast cancer, and atypical ductal hyperplasia.     

CT imaging of extraglottic airway device—pictorial review

Emergency Radiology - Compared to intubation with a cuffed endotracheal tube, extraglottic airway devices (EGDs), such as laryngeal mask airways, are considered less definitive ventilation conduit...     

ACR Appropriateness Criteria? blunt chest trauma—suspected aortic injury

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria? are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.     

Diaphragmatic injuries after blunt trauma: are they still a challenge?

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.     

Utilization of a clinical prediction rule for abdominal–pelvic CT scans in patients with blunt abdominal trauma

This study aims to determine if a clinical prediction (CP) rule to identify patients at low risk for intra-abdominal injury (IAI) is being utilized in patients undergoing abdominal computed tomography (CT) following blunt abdominal trauma. A retrospective review of adult patients with blunt abdominal trauma undergoing abdominal CT scans was performed. The CP rule was positive if any of the following were present: systolic blood pressure <90 mmHg; urinalysis >25 red blood cells/high power field; Glasgow Coma Scale score <14; abdominal tenderness; costal margin tenderness; femur fracture; hematocrit <30 %; or pneumothorax or rib fracture on chest X-ray. The CP rule was negative if all variables were negative. Acute intervention was defined as therapeutic laparotomy or angiographic embolization. All variables in the CP rule were obtained in 218/262 (83 %; 95 % confidence interval (CI), 78, 88 %) patients. Of the 44 patients without complete CP rule assessment, 1 (2.3 %; 95 % CI, 0.1 %, 12.0 %) had an IAI but did not undergo therapeutic intervention. IAI was present in 11 (6.7 %; 95 % CI, 3.4, 11.6 %) of the 165 patients with at least one CP rule positive and 4 (36 %; 95 % CI, 11, 69 %) underwent therapeutic intervention. In the CP rule-negative patients, IAI was identified in 1/53 (1.9 %; 95 % CI, 0, 10.1 %) and no therapeutic intervention was required. An important percentage of patients undergoing abdominal CT are not assessed for or have a negative CP rule. Improved implementation of this CP rule may reduce unnecessary abdominal CT scans in patients presenting with blunt abdominal trauma.     

CT features of descending necrotizing mediastinitis—a pictorial essay

Descending necrotizing mediastinitis (DNM) is a relatively rare condition caused by downward spread of neck infections into the mediastinum. This infection previously had a much worse prognosis. In recent years, prompt computer topography (CT) diagnosis has been recommended. CT scan provides the earliest means of detecting DNM for optimal management and early surgical intervention. This paper provides an illustrated summary of our extensive clinical experience with DNM, involving 36 documented cases with CT over a 5-year period.     

Imaging of the thoracic and lumbar spine in a high volume level 1 trauma center: are reformatted images of the spine essential for screening in blunt trauma?

Reformatted CTs of the thoracic and lumbar spine (CT T/L) from CTs of the chest, abdomen, and pelvis (CT body) may be performed for screening the thoracolumbar spine in patients sustaining blunt trauma. The purpose of this study was to determine whether there was a difference in the rate of detection of spinal fractures on CTs of the body compared to the reformatted T/L spine. A secondary endpoint was to evaluate whether cases dictated by trainees improved fracture detection rate. We reviewed the records of 250 consecutive blunt trauma patients that received CTs of the chest, abdomen, and pelvis (CT body) with concurrent CT T/L reformats. Each report was reviewed to determine if there was a thoracolumbar fracture and whether a trainee had been involved in interpreting the CT body. If a fracture was identified on either report, then the number, type, and location of each fracture was documented. Sixty-nine fractures, from a total of 38 patients, were identified on either the CT of the body or the CT T/L. Sensitivity for CT body interpretations was 94 % (95 % CI: 86–98 %) compared to a 97 % (95 % CI: 89–100 %) sensitivity for the CT T/L (p > 0.5). Although the sensitivity was 97 % (95 % CI: 88–100 %) when a trainee was involved in interpreting the body CT, there was no statistically significant improvement. The results suggest that with careful scrutiny most spine fractures can be diagnosed on body CT images without the addition of spine reformats. The most commonly missed finding is an isolated non-displaced transverse process fracture, which does not require surgical intervention and does not alter clinical management. The results suggest that thin section reformats do not need to be routinely ordered in screening blunt trauma patients, unless a bony abnormality is identified on the thicker section body CT images.     

Clinical applications of susceptibility weighted MR imaging of the brain – a pictorial review

Introduction Susceptibility-weighted imaging (SWI) is a novel magnetic resonance (MR) technique that exploits the magnetic susceptibility differences of various tissues, such as blood, iron and calcification. This pictorial review covers many clinical conditions illustrating its usefulness. Methods SWI consists of using both magnitude and phase images from a high-resolution, three-dimensional fully velocity-compensated gradient echo sequence. Phase mask is created from the MR phase images, and multiplying these with the magnitude images increase the conspicuity of the smaller veins and other sources of susceptibility effects, which is depicted using minimal intensity projection (minIP). Results The phase images are useful in differentiating between diamagnetic and paramagnetic susceptibility effects of calcium and blood, respectively. This unique MR sequence will help in detecting occult low flow vascular lesions, calcification and cerebral microbleed in various pathologic conditions and aids in characterizing tumors and degenerative diseases of the brain. This sequence also can be used to visualize normal brain structures with conspicuity. Conclusion Susceptibility-weighted imaging is useful in differentiating and characterizing diverse brain pathologies.     

Usual and unusual causes of splaying of the carotid artery bifurcation: the lyre sign—a pictorial review

The ‘Lyre??sign describes the characteristic splaying of the carotid artery bifurcation due to a carotid body tumour (paraganglioma) on conventional carotid angiography. In this pictorial review, we describe and illustrate two cases demonstrating the equivalent Lyre sign on multi-detector computed tomography (MDCT) and ultrasound resulting from carotid body tumour and extra-cranial internal carotid artery pseudoaneurysm. Both of these pathologies can manifest acutely and warrant accurate diagnosis to prevent potential catastrophic consequences. We also emphasise the added value of MDCT in making a definitive diagnosis and discuss other differential considerations splaying the carotid bifurcation.     

An unusual case of bronchial rupture—pneumomediastinum appearing 7 days after blunt chest trauma

We present a case of bronchial disruption after blunt chest trauma, which is unusual because the pneumomediastinum on the chest radiograph was detected 7 days after the injury. The first day imaging methods of the thorax showed only the fractures of the first and third left rib without any complications. A computed tomography (CT) scan was done following control chest radiograph and it revealed a rupture of the left main bronchus with pleural effusion, subcutaneous emphysema and pneumomediastinum. This case shows that a finding of pneumomediastinum after blunt chest trauma should always merit further investigation of its cause, even in cases of postponed detection of pneumomediastinum and regardless of the absence of other indicators of tracheobronchial disruption. Although fiber-optic tracheobronchoscopy is considered a diagnostic golden standard, in this case, diagnosis was clearly confirmed by spiral CT scan, due to thin slices and continuous data acquisition.     

Costal cartilage fractures in blunt polytrauma patients — a prospective clinical and radiological follow-up study

Emergency Radiology - To assess the healing of costal cartilage fractures (CCFX) in patients with blunt polytrauma with follow-up imaging and clinical examination. Effect on physical performance...     

Acquired peripheral pulmonary artery aneurysms: morphological spectrum of disease and multidetector computed tomography angiography findings—cases series and literature review

Background

Acquired peripheral or intraparenchymal pulmonary artery aneurysms (PPAA) are rare entities but are important to recognize because of the associated morbidity. Hemoptysis is their principal complication and is a potentially fatal condition.

Purpose

To illustrate the causes, multidetector CT angiography (MDCTA) findings and differential diagnosis of acquired PPAA.

Materials and methods

The institutional review boards approved this study. We conducted a retrospective review of the demographic data and the results of clinical and laboratory examinations, and imaging studies of patients managed between January 2012 and January 2017 in two institutions.

Results

A total of 19 patients had acquired PPAA that were detected at MDCTA, 9 patients with normal pulmonary artery pressures and 10 with pulmonary hypertension. Nine patients developed PPAA-related acute symptoms. MDCTA features of PPAA include: a lobulated vascular mass, an indistinct irregular arterial wall, aneurysmal thrombosis or wall calcification, findings of impending rupture including perianeurysmal edema, gas or a soft tissue mass.

Conclusion

PPAA are rare. In our series, endocarditis and pulmonary hypertension are the PPAA leading causes. The treatment modality preferred is embolization, especially as surgery poses a very high risk for patients with severe pulmonary hypertension. Further clarification of the natural history of these rare arterial aneurysms is needed.

     

Hepatobiliary and pancreatic ascariasis—sonographic pictorial essay on four pediatric cases with acute biliary colic

Hepatobiliary and pancreatic ascariasis occur due to migration of the round worm ascaris lumbricoides through the bile duct orifice finally reaching the common bile duct, main pancreatic duct, intrahepatic ducts or gallbladder. These resulted in acute epigastric and right hypochondriac region colicky pain. Ultrasound is the investigation of choice in hepatobiliary ascariasis. We present here sonographic images on four pediatric patients with acute biliary colic.     

Imaging the long head of bicepstendon—a pictorial essay emphasizing magnetic resonance

Lesions of the long head of the bicepstendon (BT) are seen in association with tears of the rotator-cuff, particularly lesions of the subscapularis tendon and the rotator-interval. The frequency of positive MR-findings at the BT is approximately 25%. The pathologic alterations include complete medial luxation, subluxation and entrapment by the subscapularis tendon, tendinitis or tendovaginitis and lesions at the origin of the tendon at the superior labrum (superior labrum anterior to posterior (SLAP)--lesions). The imaging signs of BT pathology on MR include an abnormal course and position of the tendon, alterations in shape and changes in signal-intensity (SI), obliteration and thickening of the tendon-sheath. In long standing intra-articular BT rupture, neo-insertion of the tendon in the bicipital sulcus may ensue. The long BT needs to be visualized in transaxial, coronal oblique and sagittal oblique projections. Besides serving as stabilizer of the long head of biceps muscle, the BT is also an important stabilizer of the anterior joint capsule.     

MDCT in emergency radiology: is a standardized chest or abdominal protocol sufficient for evaluation of thoracic and lumbar spine trauma?

OBJECTIVE: The objective of our study was to assess the diagnostic performance of a standardized 4-MDCT trauma protocol for the evaluation of the thoracic and lumbar spine in patients with multiple injuries. MATERIALS AND METHODS: Eighty-two patients with multiple injuries underwent MDCT for the chest and abdomen using a standardized 4-MDCT trauma protocol (collimation, 4 x 2.5 mm). Secondary reconstructions targeted to the spine were performed (slice width, 3 mm; reconstruction interval, 1.5 mm). All spinal fractures were additionally scanned using a collimation of 4 x 1 mm, and these images served as the standard of reference for fracture classification. An additional 50 patients with no spinal fracture served as the control group. A total of 65 major spinal fractures were present in 55 of the patients with multiple injuries. Two observers (observer 1 and observer 2) independently evaluated all CT data for spinal fractures using a 5-point confidence scale, classified the different fracture types, and rated the image quality of spinal structures on axial images and multiplanar reformations. RESULTS: Image quality for axial images was excellent in 80% and in 68% using 4 x 1 mm and 4 x 2.5 mm collimation, respectively. Image quality of the multiplanar reformations was excellent in 75% and good in 65% using 4 x 1 mm and 4 x 2.5 mm collimation, respectively. Spinal fractures were detected by observer 1 and observer 2 with a sensitivity and specificity of 98% and 97% and of 97% and 97%, respectively. Interobserver agreement regarding the confidence scale for fracture detection was substantial (kappa = 0.80), and agreement between the different imaging protocols for fracture classification was excellent for observer 1 (kappa = 0.95) and observer 2 (kappa = 0.97). CONCLUSION: Accurate evaluation of the thoracolumbar spine is possible with targeted image reconstruction based on a standardized 4-MDCT trauma protocol of the chest and abdomen.